=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558780940
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAVERICK JOSEPH LEBLANC MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2014
-----------------------------------------------------
Last Update Date | 08/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2601 E ROOSEVELT ST
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85008-4973
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-344-1516
-----------------------------------------------------
Fax | 602-344-1004
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2929 E THOMAS RD
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85016-8034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-470-5560
-----------------------------------------------------
Fax | 602-470-5064
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 2017043788
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 322598
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 66556
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------